ASSESSMENT| GOAL| INTERVENTIONS| RATIONALE | EVALUATION| O: 61 year old post op pt has gone cholecystectomy. Pt is nonverbal and immobile. Pt has stage 2 breakdown on scrotum and stage 1, 2x2 redness around anus Nursing Diagnosis:Impaired skin integrity related to physical immobilization AEB Stage 2 skin breakdown on scrotum, and stage 5 skin impairment on anus Theoretical Knowledge:Targeting variables can focus assessment on particular factors and help guide the plan of care and prevention | 1. 1 pt will not have breakdown of skin around anus throughout shift 2. 1 Report any alteration in redness or pain at site of skin impairment q4 hrs3. 1 Regain skin integrity of skin surface within a month | 1.1 Assess site of skin impairment and determine etiology. Implement position changing to reduce pressure of site. 0800 Pressure ulcer Stage 1 break down around anus, stage 2 breakdown on scrotum.0900 cleaned bowel movement and applied topical ointment. Positioned pt on left side line position.Wound was very red, and breakdown was present around scrotum1100 cleaned bowel movement, applied topical ointment and positioned client on right side lying position. Applied a dressing cushion around anal area. 2.1 Monitor site of skin impairment at least twice a day for color changes, redness swelling or other signs of infection.0900 Cleaned bowel movement and applied topical ointment. Wound was very red, swollen and breakdown was present around scrotum1100 Cleaned...

...﻿Assess the individual in a health and social care setting
1. Understand assessment processes
1.1 Compare and contrast the range and purpose of different forms of assessment
There are many forms I use to assess an individual’s needs. The first bit of the information comes from Derby City Council, which is called a outcome based support assessment. This is what they use to identify someone’s needs and how much care they require. The information on this document is great for Derby City to use, but I also need to do my own and adapt it so it’s easier for a care worker to understand as they are the ones who will be doing the care. It’s important that I read this document before going out to do my own careplan as it gives me a bit of back ground information first. Especially if it states someone has Alzheimer’s or Dementia as I know, I will have to contact the family to arrange for them to be present at the service users property as well as the service user.
The way I assess a service users needs is by visiting them and talking to them about what care needs they require, why they think they need care and where they think there strengths and weaknesses are. I find it easier to talk with them instead of asking straight forward questions as people tend to open up more and you can get a far clearer picture and a lot more information from someone once you start having...

...If at any time the blood flow is disrupted and unable to reach certain areas, skin tissue will become starved of oxygen and eventually begin to break down and die, resulting in a pressure area. People with normal mobility don’t develop pressure sores as their body automatically makes hundreds of movements that prevent this from happening. A good example to use to explain this would be sleeping in bed. Although we think we are laid still, without us even realising, we move positions numerous times throughout the night because after lying in a position for so long we start to get uncomfortable. After reading up on pressure areas I have found out that some pressure areas can just be an inconvenience for some people that require minor nursing care and some can be potentially life threatening with a high risk of blood poisoning and or gangrene. Skin is the largest organ of the body, covering and protecting the entire surface of the body. The total surface area of skin is around 3000 sq inches or roughly around 19,355 sq cm depending on age, height, and body size. The skin, along with its derivatives, nails, hair, sweat glands, and sebaceous glands forms the integumentary system. Besides providing protection to the body the skin has a host of other functions to be performed like regulating body temperature, immune protection, sensations of touch, heat, cold, and pain through the sensory nerve endings, communicating with external openings of numerous other body...

...Indiana
Nursing Program – Region 6
Nursing CarePlan and Evaluation
Student: __ Instructor: _Date: _1-28-2010_____
Instructions:
1. The nursing careplan evaluation is based upon the application of criteria appropriate for the student’s skill set.
2. All nursing careplans must be typed (Times New Roman, 12 point font). The nursing careplan form is available on Blackboard™ in each clinical course.
3. The grading rubric must be attached – last page of nursing careplan.
4. All relevant assessment tools used (physical, psychological, or psychiatric i.e. Braden Skin Assessment, Fall Risk) must be attached.
HIPAA (Health Information Privacy and Protection Act) mandates all health care providers protect patient privacy. Only information that the patient specifically releases may be shared with others. Only professional persons (students and instructors) involved in care are allowed access to the health care information. The student should be cautious about what information is shared verbally and with whom. If the student is approached for patient information by someone who purports to have authority, the best course of action is to refer that individual to the appropriate administrative personnel.
IVY TECH COMMUNITY COLLEGE OF...

...Data Base and Nursing CarePlan
Student Name: Date:
Pathophysiology (Include Normal Physiology, identify the Physiological Alteration, identify sings and symptoms).
M.P. is a 56 year old African American male, with a history of progressive multiple sclerosis with multiple contractures, chronic decubitus ulcers, chronic indwelling urinary catheter and known osteomyelitis (infection of the bone). Mr. P. was admitted on October 25th with sepsis, a systemic response to infection. He presented with a fever (102.7 F), confusion, tachycardia, and tachypnea and elevated WBC.
Multiple sclerosis is a chronic disease of the central nervous system in which the myelin sheath are destroyed in regions of the brain and spinal cord. This results in temporary repetitive disruptions in never impulses conduction which causes symptoms of muscular weakness, loss of coordination, numbness, visual disturbances, and loss of bowel and bladder function. Mr. P has secondary progression of the disease which may result in a gradual accumulation of visual, motor or sensory disabilities. The cause of this disease is unknown (Tabers, 2005).
Patient is full care related to his diagnosis of multiple sclerosis because of being unable to straighten legs. He currently lives at the VA in the Community Living Center. Patient must be kept on a strict turn schedule because of his multiple pressure ulcers. Patient also have PEG (percutaneous...

...oxygenation to parts of their body, and interventions may include administering analgesics to treat the discomfort, of which an adverse effect may include an altered breathing pattern, it is especially important to pay attention to and assess respiratory functioning in order to treat the effects of smoking and administration of analgesics on respiratory function and assure adequate oxygenation.
3. Disturbed Sleep Pattern related to excessive noise as evidenced by reports of being awakened all night. Disturbed sleep pattern should be prioritized third, because lack of adequate rest can cause fatigue, further discomfort, and decreased ability to function and perform ADL’s which is important to a client’s self-esteem and independence.
Nursing CarePlan
Nursing Diagnosis: Acute Pain related to vaso-occlusive crisis secondary to sickle cell anemia as manifested by grimacing and verbalization of pain
Outcome/Short Term Patient Centered Goals Planning/Interventions
Implementation Rationale for interventions Evaluation
Short-Term Desired
Outcomes
The client will “perform appropriate interventions, with or without significant others, to improve and/or maintain acceptable comfort level,” a 5 or less on a 0-10 pain scale, by the end of the day (Ackley & Ladwig, 2013).
Long-Term Desired
Outcomes
The client will “identify strategies, with or without significant others, to improve and/or maintain comfort level” by the time of discharge (Ackley...